'It’s laughing in the face of tragedy,' says Dr. Brian Goldman

Dr. Brian Goldman had just finished his first exhausting night on call as a resident at Toronto’s Hospital for Sick Children when the senior resident asked with seemingly genuine sincerity how many patients Goldman had “boxed” that night, meaning put into a coffin.

He was joking. But the moment marked Goldman’s initiation more than 30 years ago into what he describes as one of medicine’s darkest and most enduring secrets, the slang and coded words used by the healing profession to describe certain patients and situations.

As Goldman, an emergency physician at Mount Sinai Hospital in Toronto and host of CBC Radio’s White Coat, Black Art, reveals in his new book, The Secret Language of Doctors: Cracking the Code of Hospital Slang, it isn’t pretty.

Obese patients are “whales” or “beemers”

Obese patients are “whales” or “beemers,” a play on BMI, or body mass index. “Frequent flyers” and “cockroaches” are patients who return to the ER again and again. Old people are known as FTDs, or “failure to die” — the patient whose “mind is long gone but the body is chugging along,” as one veteran ER doctor described them to Goldman.

It’s intended to be funny, in a dark way. “It’s laughing in the face of tragedy,” Goldman says. “We’re exposed to horrible things and sometimes you need to communicate it.”

But much of the slang is flip, insulting and denigrating. Most is directed at the “undesirables” — the frail elderly, the demented, the morbidly obese, the addicted and the mentally ill, and if doctors don’t much like treating these patients, Goldman writes, “we like each other even less.”

Old people are known as FTDs, or “failure to die”

“Much of the venom spewed in the Bunker (the room hidden behind the nursing station where medical staff discuss patients) is reserved for colleagues,” he writes. “We’re supposed to be a team of health professionals, yet we act like a bunch of rabidly competitive and sometimes even bitter rivals.”

One of the central canons of the Canadian Medical Association’s code of ethics is that doctors practice medicine “in a manner that treats the patient with dignity and as a person worthy of respect.”

The College of Physicians and Surgeons of Ontario also has a practice guide “that articulates our expectations of the medical profession,” said spokeswoman Kathryn Clarke. “One of the key sections is the duty to communicate with patients and with others in a way that reflects civility and professionalism.”

Status dramaticus: “irritatingly, overanxious” patients who are convinced they are dying.

Goldman doesn’t encourage slang, but he says outlawing it would ignore the reasons it flourishes.

Doctors call obese patients “whales” because they aren’t being taught obesity is a disease, he says. Doctors get frustrated with elderly patients because they are “astonishingly ignorant about how to take care of older patients.”’ For doctors who aren’t psychiatrists, assessing and treating a psychiatric patient in the ER “is almost like voodoo,” he says. “We don’t understand it.”

The following is an edited transcript of an interview with Postmedia News:

How do you think your colleagues will feel about you sharing the secret code with patients?

I think of this book as how doctors talk. We’re all indoctrinated; we’re kind of inoculated as medical students and residents as part of a bonding experience. I wanted to use it as a lens to talk about the culture of modern medicine. I believe health professionals are wonderful people; they’re among the most ethically grounded people on the planet. But they have their foibles and frustrations.

Why is so much mean-spirited slang directed at the obese?

When it comes to morbid obesity this is the last vestige, the last refuge of utter prejudice, where it is socially acceptable even for doctors to dis morbidly obese patients. That’s because we, all of us in society, tend to denigrate people who are bariatric patients, people who weigh 400 or 500 pounds. That’s why in each chapter I not only discuss the slang, but I recruit a champion, someone who can give us the straight goods.

Unless you’re specially trained, unless you’re specially sympathetic or empathetic to bariatric patients, you see the weight and you don’t see the person inside.

(But) if you’ve got a hospital that doesn’t have stretchers for people who weigh 600 or 800 pounds, or wheelchairs or beds that aren’t weighted for bariatric patients and they fall to the ground — and they will fall to the ground and someone has to pick them up — you can understand the frustration.

Why does slang continue to flourish?

Dr. Peter Kussin, who is a slangmeister from Duke University, said you could unpack a lot of information in a slang term like “circling the drain.” It’s slang for a patient who is almost certainly going to die, as opposed to “entering the drain” where you are teetering on the brink. In three words you’re able to say, “we’re providing comfort measures only, we’re not trying heroic measures in this case.”

A multi-page birth plan is a “C-section consent form.” Why? Because a multi-page birth plan will have a million things on it: I want a doula, I want my midwife here, I want Hey Jude playing, I want no epidural, I want no fetal heart monitoring … the last thing that would ever appear would be a consent to a C-section.

It speaks to the law that we have in medicine, that the most anxious patients who dread a particular complication, they’re the ones who are going to get it.

Slang also speaks to the frustrations with the kind of patients we increasingly have to see. Patients who are “frequent flyers,” patients who have no better place to receive primary care. Aging patients — patients that we think are futile, and that trying to provide exquisite state-of the-art acute care is an exercise in utter futility, and yet there they are, and if the family doesn’t sign a “do not resuscitate” or “allow a natural death” form, then we have to do full bore resuscitation.

Do you use slang?

I use it a lot less, particularly since I wrote the book. My father passed away in October. He was in and out of hospital a lot in the two or three years before he passed away. My mother has advanced Alzheimer’s disease.

I still love my colleagues and some of them do wonderful work. But I’ve seen a kind of lack of empathy that I find disturbing. It’s almost as if the only cure for that lack of empathy is either be a patient or be the loved one of a patient.

From The Secret Language of Doctors:

Frequent flyers: People who visit the emergency department over and over again. Some doctors and nurses Goldman interviewed call them “cockroaches.”

In the departure lounge: a patient who is dying

Discharged up: “a casual and flip way of saying a patient has died.”

Turfing or dumping: “Finding any excuse to refer a patient to a different department or team.”

Bounced: When a turfed patient is punted back to the doctor that turfed her in the first place.

Entering the drain: patients “teetering on the brink of death.”

Circling the drain: “the patient has entered the inevitable phase and can’t be saved.”

Failure to die: patients at or near the end of life who continue to live for weeks or months

FOOBA: “found on ortho barely alive.” “It’s a dig at orthopedic surgeons, who have a reputation for being so focused on what needs to be fixed surgically that they ignore signs of other diseases.”

GOMER – “get out of my emergency room”

Status dramaticus: “irritatingly, overanxious” patients who are convinced they are dying. “Call it two per cent real symptoms and 98 per cent performance.”

Darwin award: “slang for a woman who chooses to have a high-risk birth at home — far away from a hospital with its life- and womb-saving doctors and equipment. It’s a reference to the annual Darwin Awards given to individuals who carry out colossally stupid or foolish acts that often end in death.”

Whiney-primey: a woman with a first pregnancy who keeps going to the labour and delivery ward thinking she’s in labour when she isn’t.

Princess: a woman in labour who wants an epidural the moment she enters the hospital.

Caesarean section consent form: slang for a multi-page birth plan. “For whatever reason, be it scientific or chance, women who show up with birth plans tend to have labours that go anything but according to plan.”

Beemers: people with a high body mass index, or BMI

Harpooning the whale: inserting an epidural catheter into an obese woman in labour

Yellow submarine: an obese patient with liver cirrhosis

Splitters: people with borderline personality disorder

PITA — acronym nurses use for “pain in the a**”

Horrendoma: a horrible or awful condition or situation

Dyscopia: bad or difficulty coping

Acopia: complete lack of coping skills

Peek-and-shriek: slang used by surgeons that describes “taking a patient to the operating room, opening the belly (peek) and realizing the patient has a condition that cannot be fixed (shriek).”

Flogging: as in flogging the patient with all manner of treatments for things “that either can’t or shouldn’t be fixed.”